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I-SBAR FOR DIRECT PATIENT CARE DOCUMENTATION
ANTEPARTUM/INTRAPARTUM
I
Introduce yourself
Your Name: Your Title: Reason for being there:
D#:
S
Situation
Patient Initials:
EDC: LMP: Other:
Singleton Twin Other
Reason for Admit:
Fetal Movement: Present
Membrane Status: Intact
Age: G____T____P____A____L____
Gest. Age: /7 weeks
Not Present:
Ruptured Date Time: Fluid:
B
Background
Previous Pregnancies:
Current Pregnancy Prenatal Care: ❑ Yes ❑ No GBS Status: ❑ pos ❑ neg Breast Feeding: ❑ Yes ❑ No
Labs:
Complications:
Past Medical History: Family Support:
Home Medications:
A
Assessment
Vital Signs
Labor status: onset: stage /phase:
Vaginal exam: _____/______/______ Blood/fluid ____________________
Planned method of delivery: vaginal c/section
Fetal heart rate pattern: reassuring non-reassuring
Contraction pattern: frequency duration strength
Labor progress:
Maternal physical assessment:
IV: CURRENT MEDS:
Labs:
Activity:
COLLEGE of NURSING
National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu
Please visit chamberlain.edu/locations for location specific address, phone and fax information.
12-200085 ©2020 Chamberlain University LLC. All rights reserved. 0420culcpe
YEAR TYPE OF DELIVERY LABOR LENGTH COMPLICATIONS
TEMP B/P HR RR SP02 PAIN FHTS
I-SBAR FOR DIRECT PATIENT CARE DOCUMENTATION
ANTEPARTUM/INTRAPARTUM
R
Recommendation
Discharge Planning Needs:
Plan of Care:
Nursing Analysis/Priority Diagnosis:
Patient Goal:
Outcome Criteria:
Met/ Not met/Partially met
PRIORITY INTERVENTIONS REASONING EVALUATION OF INTERVENTION
1.
2.
3.
4.
5.
COLLEGE of NURSING
National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu
Please visit chamberlain.edu/locations for location specific address, phone and fax information.
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